The ABC’s of Revision Posted by Eric Schlesinger, MD, FACS on obesityhelp.com "revision" forum
Stomaphyx is a safe and effective way to decrease the size (volume) of your pouch and its outflow tract. You may have read that Stomaphyx does not "tighten up" the stoma. This statement is misleading. Although no fasteners are place in the stoma, the concentric pleating immediately above the stoma will "tighten up" the out flow from your pouch. Think about your garden hose. Pinching the hose will narrow its opening and restrict the flow of water. Where ever you pinch the hose, this maneuver will have the same effect. So, even though no fasteners are placed in the stoma, properly performed, Stomaphyx will effectively "tighten up" your stoma. Due to its minimally invasive approach, LOW risk and the universality of some degree of pouch and stomal dilatation, pre-Stomaphyx upper GI's or endoscopies (separate anesthesia) are not an absolute prerequisite. Pouches with a volume, capacity of over 250 cc (normal 15-30 cc) are better addressed with procedures other than Stomaphyx.
Dr. Ellner at Alvarado Hospital in San Diego has just started to do this revision. She is the only local bariatric surgeon in San Diego County doing it. It costs $10,000 and is not covered by insurance. It is too soon to know if it will help long term.
The Basics
The best place to begin our journey is a review of the principles of WLS. These principles are every bit as pertinent to revisions as they were to your initial procedure. With the exception of "the sleeve" (VSG), all WLS procedures reside along a spectrum. At one end of the spectrum are the essentially restrictive procedures and at the other end of the spectrum are the highly malabsorptive operations.
Restrictive operations work by severely limiting the amount of food your are able to eat at a given meal.
The most commonly performed essentially restrictive procedure is the Lap-Band. The Lap-Band is a silicon ring that is placed around the upper portion of the stomach. The "pouch" created in this procedure is the upper portion of the stomach. Ideally the Lap-Band "pouch" should have a volume of 1/2 fluid ounce or 15 cc. "Pouch" sizes up to 1 fluid ounce (30 cc) are acceptable. Anything larger is not sufficiently restrictive. The Lap-Band is currently the only procedure which is adjustable without another operation. The outlet of the "pouch" can be tightened by inflating the "balloon" on the inside of the band with salt water (saline). Tightening the Lap-Bang increases the restriction by narrowing the outlet of the "pouch".
Highly malabsorptive operations create a very short common conduit, thereby preventing you from absorbing much of the nutrients in the food you eat. The common conduit is the part of the intestine which sees both food and digestive juices. Classic malabsorptive procedures have a common conduit of between 50 cm and 100 cm. The shorter the common conduit, the less nutrients your body is able to absorb.
Highly malabsorptive procedures are the duodenal switch (DS), extended Roux-en-Y (ERny), and the less commonly performed bilio-pancreatic diversion (BPD). In the ERny nothing is removed. In the DS and BPD a large portion of the stomach is removed at surgery. The "Dumping Syndrome" will likely occur after the ERny or BPD, but not the DS.
In between the essentially restrictive procedures (Lap-Band) and the highly malabsorptive operations (ERny, DS, and BPD) is the "classic" gastric by-pass (Rny). Rny's are excellent restrictive operations. The Rny "pouch" is constructed to be able to hold between 1/2 and 1 fluid ounce. The stoma (pouch outlet) should be about 12 mm in diameter. There are two basic varieties of the "classic" Rny, proximal (most common) and distal. The difference between the two is the length of small intestine which is excluded from "the food stream". The proximal Rny excludes 150 cm of the small bowel or less. The distal Rny excludes 150 cm or more of small bowel (classically no more than 250 cm). Excluding more small intestines from the food stream increases the malabsorptive component of the Rny. Neither the proximal or "classic" distal Rny is a highly malabsorptive procedure.
The "
sleeve" (VSG) works in two ways. There is a restrictive element to the VSG. However the restriction created by this operation is insufficient to explain its successful results. Part of the efficacy of the "sleeve" is due to the reduction in grehlin levels caused by removing a large portion of the stomach. To date it is not known how long this reduction in grehlin will persist.
These principles will not only give you a clearer "picture" of your initial operation; they will enable you to better understand revisionary surgery. Armed with this information you will be able to actively and intelligently participate in any discussion of your revision. Now that we are all speaking the "same language"; let the dialogue begin.
Weight Regain I
Weight regain after a "classic" Rny is NOT unusual. In fact it occurs so frequently that your bariatric surgeon should have discussed this with you at your initial consultation.
Often the first question I am asked by a patient interested in a revision is; "What did I do? How did I break my "tool"?" While these are not unreasonable questions; they are not the correct ones. It is EXTREMELY difficult to "break your tool." Sadly, many surgeons "feel better" if they can blame their patients. I recently saw a young lady who had her Rny performed by another surgeon. She had regained nearly all of the weight she had lost. Her after care left much to be desired. In spite of this, she scheduled an appointment with her bariatric surgeon to learn what could be done. Unless this woman had been flagrantly disregarding her nutritional program (she wasn't), her weight regain was NOT her fault. None of us is perfect. Everyone "cheats" from time to time. I tell all of my patients that they are entitled to a treat. Allow yourself a treat from time to time and when you do treat yourself, make it special. While these treats may lessen your weight loss, if they are limited to special occasions, they will not result in significant weight regain.
OK, then why do Rny patients experience weight regain? There are three factors that contribute to this weight regain.
First, the pouch has a tendency to "stretch" over time. Different pouches stretch differently. Pouches based off of the right side of the stomach (lesser curve) stretch less than pouches based off of the left side of the stomach (greater curve).
Second, the stoma (connection between the pouch and small intestine) also has a tendency to enlarge over time.
Third, the body is a miraculous thing. It is constantly adapting and changing. Over time your small intestine adapts to its reduced length by becoming better at absorbing the nutrients that are presented to it. It becomes more efficient.
In summary, through no fault of your own (unless you have been flagrantly abusing yourself and your operation), both the restrictive and malabsorptive components of your by-pass will diminish. That is why a degree of weight regain is the norm; not the exception.
So, what can we do about it? That is the topic for a future posting.
Remember; there are NO failures, only those who have yet to succeed!
Revisions for Rny'ers
There are two major aspects of a by-pass that may be revised. The restrictive component and the malabsorptive component.
Restriction
As we have discussed, it is common to be able to eat more months to years after your initial surgery. There are many different reasons for this. I will mention only in passing that a small component of this is the skill that you have developed with experience. You have become experts at eating slowly and chewing your food thoroughly. You have learned what "sits" well and what doesn't. If your pouch wasn't too large when it was constructed, it is prone to "stretch" over time. The same is true for your stoma. This does NOT mean that you did something wrong. In many ways it is as inevitable as the sun rising tomorrow. So your pouch/stoma is dilated, now what?
There are several different approaches to dealing with this.
Stomaphyx is a safe and effective way to decrease the size (volume) of your pouch and its outflow tract. You may have read that Stomaphyx does not "tighten up" the stoma. This statement is misleading. Although no fasteners are place in the stoma, the concentric pleating immediately above the stoma will "tighten up" the out flow from your pouch. Think about your garden hose. Pinching the hose will narrow its opening and restrict the flow of water. Where ever you pinch the hose, this maneuver will have the same effect. So, even though no fasteners are placed in the stoma, properly performed, Stomaphyx will effectively "tighten up" your stoma. Due to its minimally invasive approach, LOW risk and the universality of some degree of pouch and stomal dilatation, pre-Stomaphyx upper GI's or endoscopies (separate anesthesia) are not an absolute prerequisite. Pouches with a volume, capacity of over 250 cc (normal 15-30 cc) are better addressed with procedures other than Stomaphyx. Tubular pouches are better suited for Stomaphyx than globular or spherical pouches. Right sided stomas are better suited for this treatment than left sided stomas. Having said this, I have had excellent results with unfavorable pouches and stomas.
Lap-Band over Rny can result in a dramatic improvement in restriction. Before a Lap-Band over Rny is performed the pouch must be evaluated with either an upper GI (X-Ray) or an upper endoscopy. While relatively small pouches can benefit from Stomaphyx, small pouches will NOT benefit from a Lap-Band. The reason is simple mechanics. If the pouch is too small to be "pinched" by the Band, the Band will serve no purpose. Lap-Band over Rny carries a higher risk than Stomaphyx. As in all weight loss surgery, the procedure chosen must be "matched" to the patient's anatomy, physiology, emotional make up, needs and desires. With the proper match, Lap-Band over Rny will yield excellent results.
The pouch and stoma can be surgically reconstructed. This approach carries with it risks that are even greater than Lap-Band over Rny. The stomach is much more unforgiving after it has been operated on once. The risk of a leak is significant. In fact, this risk is the major contributing factor for the reported "high risk" of revisions. Additionally, the surgically revised pouch and stoma is not immune from "stretching" again.
Eric Schlesinger, MD, FACS
AZ Weight Loss Solutions
http://www.obesityhelp.com/forums/revision/board_id,5360/user_id,773880/a,messageboard/action,memberPosts/
Stomaphyx ? -Gastric bypass revision ?
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